Fill and Sign the Order to Dismiss or Withdraw for Workers Compensation Illinois Form

STATE OF ILLINOIS ) ) COUNTY OF       ) ILLINOIS WORKERS’ COMPENSATION COMMISSION ORDER TO DISMISS OR WITHDRAW PETITION UNDER SECTION 19( b -1) OF THE ACT       Case #       WC       Employee/Petitioner v.             Setting       Employer/Respondent On       , this case was set for a trial pretrial under Section 19(b-1) of the Act in the city of       , Illinois. I hereby order the following: The petition is dismissed for the following reasons:       The petition is withdrawn, in response to the petitioner's request. A record of the hearing was was not made. This order shall not be a bar to any further hearings on this case or any subsequent petitions under Section 19(b) or 19(b-1) of the Act. Unless the parties appeal this order within 30 days of its receipt and perfect the review in accordance with the Act and Rules, this order will be entered as the decision of the Commission. If the petition was withdrawn, or if the parties agree below, the order may not be appealed. If this order is appealed, and the order is not affirmed by the Commission, the time limit provided by law for filing the final decision shall be tolled until the Commission issues its decision. ____________________________________________       Signature of arbitrator Date S TIPULATION The parties agree this order should be entered. The parties agree that the petitioner may refile the Petition for an Immediate Hearing at the arbitrator's status or trial date on       , as long as the petitioner gives the respondent some prior notice. The parties do not need to refile or re-serve any of the original documents that were attached to the original petition. ____________________________________________ __________________________________________ Signature of petitioner or petitioner's attorney Signature of respondent or respondent's attorney             Name of petitioner or petitioner's attorney (please print) Name of respondent or respondent's attorney (please print) IC14d 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084